A comparative study between skin sutures and
skin staples in abdominal surgical wound closure
Dr. Chandrashekar N., Dr. Prabhakar G.N., Dr.Shivakumarappa G.M.,
Dr.Fahad Tauheed.
Address for correspondence:
Dr. Chandrashekar N., Associate Professor,
Department of General Surgery,
Sree Siddhartha Medical College, Hospital & Research Centre,
Tumkur-572107,
Karnakata.
Abstract
The skin stapling devices have revolutionized surgery for the purpose of rapid
closure of abdominal wounds. However, staples have their own drawbacks. In
view of this, this prospective study has been undertaken to highlight the outcomes
of closure by staples and sutures with respect to speed of closure, cost
effectiveness and post operative wound dehiscence, acceptance of scar and post
operative pain. This is a prospective hospital based study conducted in our hospital
from October 2009 to September 2011 involving a total of 200 patients who
underwent abdominal surgery both on an emergency and elective basis. Results
were analyzed and compared with previous studies.
It has been found that the use of staples in abdominal surgical wound closure gives
faster speed of closure, less postoperative pain, and better cosmetic results. Staples,
however, are costlier, and when used in emergency cases, associated with higher
rates of wound dehiscence and a less acceptable scar.
Keywords
Skin staples, nylon suture material, post operative wound infection, operative scar.
Introduction
Any surgical intervention will result in a wound in order to get access to and deal
with the underlying pathology. In this situation, the surgeon's task is to minimize
the adverse effects of wounds, remove or repair the damaged structures and
harness the process of wound healing to restore function.
The principle aims of tissue repair of surgical skin incisions are rapid acquisition of
strength and minimum tissue damage, with minimum inflammation and a good
scar. Many factors including the choice of suture materials and its placements
influence these aims; of particular relevance is the accurate co-optation of dermal
edges; eversion or inversion leads to sub optimal healing.
For many years sutures have been used to approximate the skin edges, and also to
hold the cut tissues together until the wound has healed sufficient enough as to be
self supportive. Throughout antiquity many materials have been used to
approximate the skin edges. Suture technology and suture sterilization have kept
pace with advancement in surgical techniques and provided the surgical fraternity a
wide range of sutures in different size as fine as 30 microns. Now the surgeon has
at his disposal a wide variety of suture materials like natural and synthetic, non
absorbable and absorbable, monofilament to poly filament. However, sutures have
the disadvantage of consuming more time in applying and with a cosmetically
inferior scar. The use of other methods to approximate the wound edges like
stapling devices, glue or adhesive tapes have becoming more popular of late to
overcome these disadvantages. At present, cost effectiveness is debatable.
Material and Methods
This proposed study was conducted at Sree Siddhartha Medical College, Hospital
and Research Centre, Tumkur, Karnataka, over a period of 2 years from October
2009 to September 2011.
The study included 200 patients who underwent abdominal surgeries, including
both emergency and elective surgical procedures. All patients with abdominal
surgical wounds were included, but excluded from the study were patients with
skin infection, patients with post burst abdomen, wounds secondary to burns, all
patients with anemia and diabetes. The patients were allotted alternately into two
groups of 100 each. In group 1, abdominal wound closure was done (using 2-0/3-0
monofilament nylon) with mattress sutures. In group 2, abdominal wounds were
closed with surgical skin stapling device.
The outcome was measured in terms of:
1. Speed of closure.
2. Cost effectiveness.
3. Post operative pain.
4. Post operative wound dehiscence.
5. Acceptance of the scar.
Results were analyzed and compared with the previous studies.
Results
Speed of closure.
Speed of closure was faster with staples. The average duration of closure was
8minutes in suture group and 60 to 70 sec in staples group. The abdominal wound
closure in case of staples group was hence 5 to 7 times faster in comparison to
suture group (on an average the length of abdominal surgical wound was 12 to 15
cms).
Postoperative pain
Post operative pain assessment was done using visual analog score. Immediate post
operative pain scores were higher with the use of sutures as compared to staples in
both elective and emergency cases. 56% of elective cases in whom suture closure
was used had a pain score of 3 or higher, compared to only 17.2% in staple closure
group. For emergency cases, the figures were 84% for the sutures group and 14.3%
for the staples group.
Post operative wound infection and dehiscence
Post-operative wound infections were marginally higher (almost comparable) in
staples group (13.7%) compared to sutures group (12%) in elective cases; but
significantly higher in staples group (38.09%) compared to sutures group (16%) in
emergency cases.
Cosmetic results.
Cosmetic results were better with staples in elective cases. However when staple
closure was used in emergency cases, post operative wound infection and
dehiscence were higher and hence healing was with secondary intention; the
resultant scar was thick and cosmetically less acceptable. (scars were compared
after 3 months of surgery)
Cost
The average median cost in suture group was Rs 100/- and in staple group Rs 310/. Staple closure was hence thrice as costlier as sutures.
Discussion
Wound closure is a vital step for producing a healthy and strong scar and also for
ensuring aesthetically pleasing appearance.
Surgical stapling was developed in 1908 by a Hungarian surgeon, Humer Hultl1.
The original instrument was massive by today's standards weighing 7.5 pounds.
Modifications performed by Von Petz provided a lighter and simpler device, and in
1934 Fredrick of Ulm designed an instrument that resembled the modern linear
stapler. In 1958, Ravich, refined the instruments to their current state and wide
spread use today2.
Staplers are made up of stainless steel. They are virtually inert. They have uniform
shape and constant staple depth providing even wound tension. Rectangular shape
design minimizes the trauma and minimizes the tissue compression thereby
causing minimal tissue reaction and trauma and leads to wound healing with
minimum scar.
The development of disposable skin staplers has made this method of wound
closure an increasingly popular technique. Skin staplers are quick and easy to use
and numerous studies have confirmed the speed and efficacy of staping compared
with suture repair.
Eldrup et al (1981) analysed 137 patients undergoing abdominal or thoracic
surgeries, and concluded that the main advantage of using staples was the time
saved, as closure with mechanical suture took one third of the time required for the
conventional method. On the other hand closure with staples resulted in the major
disadvantage of additional expenses, as the cost was forty seven times higher than
that of the suture with Dermalon3.
Meiring et al (1982) reported slightly better cosmetic results in a group of 40
patients undergoing laparotomy with an 80% in time saving. They also concluded
that the final cost of the stapler was crucial for selecting the method 4.
Gatt et al (1985) concluded from a controlled trial of staples for wound closure that
the speed and convenience of the skin staples outweigh the extra cost5.
Lubowski and Hunt (1985) consider proximate staple closure a suitable and faster
method for vertical abdominal wound compared to sutures6.
Stockey and Elson (1987) compared the results of closure with staple and nylon
sutures found a higher incidence of inflammation, discomfort on removal and
spreading of the healing scar with staples. The only advantage of staples was speed
of wound closure7.
Ranabaldo and Rowe-Jones (1992) compared staple with subcuticular sutures in 48
patients undergoing laparotomy and concluded that the difference in time was
significant, nevertheless, the cost was five times greater with staples8.
Luiz R Medina dos Santos et al (1995) in their study of 20 patients concluded that
the use of skin staplers speed up closure by 80%, with better cosmetic results9.
John T Kanagaye, Cheryl W Vance, Linda Chan, and Nancy Schonfeld (1997) at
the Children hospital, Los Angeles, USA, reported that staple closure was safe,
rapid and cost effective and resulted in a cosmetically acceptable scar10.
Iavazzo et al (2011) from a meta analysis of randomized controlled trials
comparing sutures with staples for the management of surgical wounds reported
that staples were faster, with fewer wound infections but associated with more pain
compared with sutures. Cosmetic results were comparable11.
In our present prospective study comparing skin sutures and skin staples for
abdominal surgical wound closure, it has been noted that though the method of
closure by the staples was significantly faster in comparison to sutures, it is met
with certain drawbacks such as post operative infection with wound gaping , and
subsequent prolonged duration of hospital stay posing economic burden on patients
and doubling the cost factor in emergency infective cases as compared to clean
elective cases.
In elective cases, the scar was found to be cosmetically superior with better patient
acceptance in staples group in comparison to sutures group. But in emergency
cases, due to post operative wound dehiscence the patient acceptance of the scar
was poorer in staples group as compared to sutures group.
The sutures were more cost effective compared to staples; the immediate post
operative pain was comparatively higher in the sutures group.
CONCLUSION
In our present study, we conclude that though the staples cost higher in comparison
to sutures, the wound closure time was much faster which was statistically
significant and in agreement with the literature reviewed. This has a great impact
on post operative recovery as the patient can be weaned off from the anaesthesia
faster and thereby reducing overall operating time and hence decreasing post
operative morbidity and mortality.
In terms of patient acceptance of scar, we conclude that staples have good
acceptance in clean elective cases and they are met with significant post operative
wound infection in contaminated and emergency cases. Since staples are easier and
faster to apply compared to sutures, the study showed that staples form an
important surgical armamentarium for wound closure for elective and clean cases.
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Post operative wound infections
Abdominal surgical wound closure by using non absorbable suture material (2-0 ethilon)
Abdominal surgical wound closure by using Disposable staple gun
Abdominal surgical wound scar after 6week follow up in staple closure
Abdominal surgical wound scar after 6week followup in suture closure